A long-awaited report from the US General Accountability Office (GAO) on physician self-referral in physical therapy is short on "definitive conclusions" and overlooks many of the realities of physical therapist practice and patient populations, according to a recent statement from APTA.

The association statement reaffirms APTA's commitment to working with GAO to foster a better understanding of self-referral and its impact, but also reasserts its position that physical therapy should not be characterized as an "in-office ancillary service" and should have never been included in the self-referral loophole to begin with.

In a report that APTA says "underscores the need for further research," GAO turned its attention to physical therapy, the last of 4 health care professions that were studied to determine the causes and percentage of increases, if any, in procedures when a physician refers a patient for treatment or services in facilities owned by the physician. Earlier studies that focused on imaging services, anatomic pathology, and radiation therapy for prostate cancer showed that the number of procedures—and costs—do in fact increase in self-referral arrangements. The study on physical therapy yielded less definitive results, due in large part to methodology limitations that GAO readily acknowledged.

Among the shortcomings cited by the association: a lack of data on severity of condition, impairments, and comorbidities, as well as on quality of care provided. "Data on the frequency of visits and total expenditures are irrelevant without knowing patient severity and outcomes," according to the statement.

The few areas in which definitive findings could be reached involved data that show a "sharp increase" in referral rates for physicians who transition to a self-referral practice model, according to the statement.

The statement also questions the report's classification of all institutional care as "non-self-referred" care, which APTA argues is more likely to involve patients with complex conditions. Given that 40% of physical therapy services billed under Medicare come from skilled nursing facilities alone, APTA says, the unbalanced nature of the 2 groups being studied "clearly skews data and clouds results."

"The bottom line is that the GAO report is unable to reach any definitive conclusions ... so the need for further research continues," according to the statement.

At some level, GAO seems to agree. The report acknowledges limitations in the methodology used, and states that "it is outside the scope of this report to examine the medical necessity, clinical appropriateness, or effectiveness of [physical therapy] services beneficiaries received."

In addition to calling for a more informed analysis, APTA is also urging policy makers to require all self-referring providers to notify patients of their right to see the provider they choose, and share lists of a variety of local physical therapists with patients. To help refine data collection, the association is also recommending that Medicare claim forms require a unique modifier that identifies when any service is being received through self-referral. APTA also continues to advocate for H.R. 2914, federal legislation that would remove physical therapy from the in-office ancillary services exception to the Stark law.

Comments

Problem here to me as a private practice is obvious. Many of the POPTS refer out Medicare b/c there don't like the one-on-one component, they issue with them not being on-site most of the time, and the cap issues. The also tend to refer those to the hospitals they are near to keep them happy for surgical priv and cases. Study really needs to look at all patients not just medicare.

Posted by dano napoli
on 6/2/2014 5:18 PM

Fraud and abuse can happen in any setting. Instead of spending so much energy trying to take away opportunities for physicians, I think the APTA should instead fight for the right of physical therapists to own physician practices. However, a more important area to focus on is eliminating the excessive regulation surrounding providing care to Medicare and Medicaid patients. The cost of healthcare would decrease dramatically if it didn't cost providers so much money just to get paid for the services we provide.

Posted by James R. Barsky, PT, DPT
on 6/7/2014 6:18 AM

We have a problem here of a small group of physicians owning not only a Physical Therapy Clinic, but also Medical Supply, and Hospice agencies. As a result, they end up controlling 40% of all healthcare in this small community so they can enrich their own pockets. They all allow their files to be worked to see what their patients "need" from each business they own and operate together, while each business is listed under a "family" member to make it look good.
The mob now has MD behind these names. Some physicians "forget" that I treat some of the conditions of their patients I believe because I will not pay under the table. This is a real problem and I don't hear anyone talking about it.
Currently, I market directly to the patients and going directly head to head with some local MDs. People choose their Pharmacist, their Dentist, and now their Physical Therapist. It is working for me. If your MD does not give you a choice of where to go for PT, chances are he is sending you to a place he has a finically interest in that business. It is your choice where to go for PT.
PS. I have been self employed for over 15 years.

Posted by Mike Stewart
on 6/9/2014 8:22 AM

The GAO did this report as "rising expenditures for PT services have long been of concern". The premise is that self referral leading to increased utilization of PT services (as occurs the year a provider begins to self-refer) is a bad outcome of that financial relationship.
What is missing from this picture is the effect of PT services on the overall cost of health care. There is reason to believe that an early referral to PT can lead to a decrease in health care expenditures for conditions such as mechanical low back pain. (If a person gets better with PT, they may avoid getting an MRI, injection or surgery.)
In many cases spending more on PT can lead to spending less overall.
When it comes to physician self-referral for PT services, the question is whether or not this is a fair business practice, and whether or not this decreases patient choices.